NUR 160-Hondros Exam 1 Study guide 2023 with complete solution

just culture - workers are protected from disciplinary action when they report injuries, errors, or near misses close-ended question - What is your name? false reassurance - Everything will be fine Why Assess? - To identify changes in pt condition, to help foresee areas of concern RN - who does the initial assessment? Within 24 hours - When should an initial assessment be done? discharge planning - What should we pay attention to when a pt is post op knee replacement and they live on 2nd floor Steps of an assessment - 1. Introduce self 2. Explain procedure 3. wash hands 4. Identify pt 5. Provide privacy 6. Inspect, auscultate, palpate Correct, then continue - If a concern arises during assessment (Ex: pt c/o SOB. Sit up, apply O2 or check tubing, teach inhale through nose, exhale through mouth) Order of assessmet - Subjective then Objective (helps to identify ares of focus) Inspect airway, auscultate lungs - If pt c/o sore throat or recent cold Serous Drainage - Clear(Good or indifferent) Sanginous Drainage - Blood-red(a little is ok, alot is bad) Serosanginous Drainage - Pink-mix of blood and serous(This is ok) Purulent Drainage - Puss (assess for infection and notify MD) Absent Bowel Sounds - Auscultate 5 mins per quadrant (Silence means NOTHING) (20 minute total) assess for an obstruction and notify MD Normal IM injection reaction - Burning at site, itching at site, bruising Abnormal IM injection Reaction - vomiting, constipation, dry mouth, rash (systemic) TB testing - 1. Must be read 48-72 hrs (assessed) 2. Document date, time of injection and reading, as well as result 3. Mild swelling is normal TB result-negative - 10mm- healthcare workers are a strict 10 TB result-positive - red, raised (induration) Positive TB result - This means that the person has been exposed to TB At risk for TB - nursing homes, jails, homeless, certain meds, some other countries, healthcare workers Hyperglycemia - hot and dry-sugar high Hypoglycemia - cold and